Provider Demographics
NPI:1073800884
Name:BOLANOS, S GINA
Entity Type:Individual
Prefix:
First Name:S
Middle Name:GINA
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 MISTY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8117 PRESTON RD
Practice Address - Street 2:STE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6332
Practice Address - Country:US
Practice Address - Phone:940-206-3028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health